State Medicaid Research Articles

Trends in Use of Medication to Treat Opioid Use Disorder During the COVID-19 Pandemic in 10 State Medicaid Programs

Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic. To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE). This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022. Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020). Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation. Among a total of 8 167 497 Medicaid enrollees before the PHE and 8 181 144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100 000 enrollees in March 2020 to 171.8 per 100 000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100 000 enrollees in March 2020 to 21.1 per 100 000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio [OR], 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE. In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.

Thematic Analysis of State Medicaid Buprenorphine Prior Authorization Requirements

Prior authorization (PA) requirements for buprenorphine are associated with lower provision of the medication for the treatment of opioid use disorder (OUD). While Medicare plans have eliminated PA requirements for buprenorphine, many Medicaid plans continue to require them. To describe and classify buprenorphine coverage requirements based on thematic analysis of state Medicaid PA forms. This qualitative study used a thematic analysis of 50 states' Medicaid PA forms for buprenorphine between November 2020 and March 2021. Forms were obtained from the jurisdiction's Medicaid websites and assessed for features suggesting barriers to buprenorphine access. A coding tool was developed based on a review of a sample of forms, including fields for behavioral health treatment recommendations or mandates, drug screening requirements, and dosage limitations. Outcomes included PA requirements for different buprenorphine formulations. Additionally, PA forms were evaluated for various criteria such as behavioral health, drug screenings, dose-related recommendations or mandates or patient education. Among the total of 50 US states in the analysis, most states' Medicaid plans required PA for at least 1 formulation of buprenorphine. However, the majority did not require a PA for buprenorphine-naloxone. Four key themes of coverage requirements were identified: restrictive surveillance (eg, requirements for urine drug screenings, random drug screenings, pill counts), behavioral health treatment recommendations or mandates (eg, mandatory counseling or 12-step meeting attendance), interfering with or restricting medical decision-making (eg, maximum daily dosages of 16 mg, requiring additional steps for dosages higher than 16 mg), and patient education (eg, information about adverse effects and interactions with other medications). Eleven states (22%) required urine drug screenings, 6 states (12%) required random urine drug screenings, and 4 states (8%) required pill counts. Fourteen states' forms (28%) recommended therapy, and 7 (14%) required therapy, counseling, or participation in group sessions. Eighteen states (36%) specified dosage maximums; among them, 11 (22%) required additional steps for a daily dosage higher than 16 mg. In this qualitative study of state Medicaid PA requirements for buprenorphine, themes were identified that included patient surveillance with drug screenings and pill counts, behavioral health treatment recommendations or mandates, patient education, and dosing guidance. These results suggest that state Medicaid plans' buprenorphine PA requirements for OUD are in conflict with existing evidence and may negatively affect states' efforts to address the opioid overdose crisis.

OUD and mental illness: Prevalence and risk of overdose

A presentation at last month's American Psychiatric Association's annual meeting revealed important findings about opioid use disorder (OUD) and comorbid mental health diagnoses. The study, by Felipe Castillo, M.D. of Montefiore University Hospital, focused on the prevalence and correlates of OUD and the risk of opioid overdose from a large state‐wide Medicaid claims database of patients. The study population (n = 523,885) included individuals 18 years and older with a mental health diagnosis recorded in the first position on at least one inpatient or two outpatient records from a clinical setting and who were continuously enrolled in New York state Medicaid during 2020. The diagnoses covered for the study excluded substance use disorders, neurodevelopmental (other than attention deficit hyperactivity disorder) and neurocognitive diagnoses alone.

KFF survey finds gaps remain in implementing crisis services

State Medicaid programs, considered the single largest payer of behavioral health services in the country, are taking steps to help implement and fund crisis services, though gaps remain, according to a new Kaiser Family Foundation (KFF) survey examining the development, implementation and coverage of crisis services.

Inflationary Rebates For Generic Drugs Sold Through Medicaid Saved Billions During 2017-20.

State Medicaid programs cover nearly all Food and Drug Administration-approved prescription drugs in exchange for mandatory manufacturer rebates, including rebates that offset price increases beyond inflation. These inflationary rebates originally applied to brand-name drugs only, but in 2017 Congress expanded them to include generics. Using public Medicaid medication spending and utilization data and three different measures of drug prices, we found that nearly half of generic drugs were subject to inflationary rebates during the period 2017-20, offsetting 2-12percent of the $53.6billion in generic drug spending during that time. Rebates were larger among non-orally administered drugs and those with the highest prices. Generic inflationary rebates offset substantial Medicaid spending during that period, suggesting that many generic prices increased above inflation despite the new policy. This might change now that inflationary rebates have been expanded to Medicare under the Inflation Reduction Act of 2022, although additional policies that ensure competitive markets would better protect all US patients from rising generic drug prices.

Association between state Medicaid policies and accrual of Black and Hispanic patients to cancer clinical trials.

1510 Background: The U.S. Medicaid health insurance program may play a key role in mitigating racial and ethnic disparities in cancer clinical trial enrollment, given Medicaid’s disproportionate representation of these populations and its coverage of the routine costs of trial participation in some states. We sought to evaluate the effect of Medicaid expansion under the Affordable Care Act (ACA) on changes in the accrual of racial and ethnic minority patients in cancer clinical trials, across all states and specifically those mandating Medicaid coverage of routine trial costs. Methods: The study used anonymous enrollment data from Medidata Rave, a large commercial clinical trial data collection platform. We conducted a retrospective difference-in-differences (DID) analysis to examine accrual demographics in states that expanded Medicaid eligibility under the ACA compared with non-expansion states, before and after expansion; and assessed effect modification based on state-mandated Medicaid coverage of routine trial costs. Participants included adults enrolled in interventional cancer clinical trials from 2012-2019, located in U.S. hospital referral regions with >5% Black or Hispanic population. The primary outcome was participant race/ethnicity, defined dichotomously as Black or Hispanic (vs non-Black, non-Hispanic). We used ordinary least squares regression to model participant race/ethnicity as a function of (1) an indicator for trial enrollment in an expansion state after policy implementation, (2) state fixed effects, and (3) year fixed effects, with standard errors clustered at the state level. To assess effect modification, we stratified the main model across states with and without coverage mandates of routine trial costs. Results: The study included 75,700 participants across 1,409 clinical trials and 351 sites. In expansion states, the proportion of participants who identified as Black and/or Hispanic increased from 13.4% before expansion to 13.8% after expansion (0.4 percentage-point [PP] change, 95% CI -0.8 to 1.7). In non-expansion states, this proportion decreased from 17.0% to 15.2% (-1.7 PP change, 95% CI -3.7 to 0.2). These trends yielded a non-significant DID estimate of 2.0 PP (95% CI -1.0 to 5.0). In stratified analyses, Medicaid expansion was associated with a 4.5 PP (95% CI 0.4 to 8.6) increase in the enrollment of Black and/or Hispanic participants in states with coverage mandates, but not in states without coverage mandates (1.1 PP, 95% CI -2.6 to 4.8). Conclusions: Medicaid expansion was associated with a significant increase in the proportion of Black and Hispanic oncology trial participants in states that mandated Medicaid coverage of the routine costs of trial participation, but not overall across all states. These findings suggest that Medicaid policies have the potential to advance equitable enrollment in cancer clinical trials.

State mandatory paid medical leave policies and survival among adults with cancer in the US.

1511 Background: Cancer treatment is often costly and time intensive. Paid medical leave can help employed patients with cancer more effectively manage side effects and complete recommended cancer treatments without loss of income. Since 2012, several states have introduced mandatory paid medical leave policies. We examined whether mandatory paid medical leave policies were associated with better survival among working age adults with cancer. Methods: Adults ages 18 to 64 years diagnosed with cancer 2007- 2019 were identified from the Surveillance, Epidemiology, and End Results registry program covering 12 states. The primary outcome was overall survival (OS). The exposure of interest was the presence of state mandatory paid medical leave policies. Difference-in-differences (DID) analyses with additive hazards regression models compared changes in OS from pre- to post- mandatory paid sick leave policy implementation in states with vs. without paid sick leave policies. Models adjusted for year-quarter fixed effects, state fixed effects, state Medicaid expansion status, age, race, sex, marital status, metropolitan residence status, county-level income, cancer site, cancer stage, and insurance status. Clustered standard errors by state were achieved via the cluster bootstrap. The plausibility of the common trends assumption was tested using event study analyses and was satisfied for all analyses. Primary analyses focused on data from 2007-2016, where information on month of diagnosis, county, and insurance coverage status were available (note these variables are not available for 2017-2019), though sensitivity analyses with data through 2019 without these additional variables were conducted. Results: A total of 1,491,208 adults with cancer were identified. In adjusted DID analyses, after policy implementation, 1-year OS improved from 85.0% to 86.4% in states with mandatory medical leave policies compared to 85.1% to 85.6% in states without such policies. This translates to a 0.85% improvement in 1-year OS (hazard DID: -0.0007, 95% CI = -0.0016 to -0.0001, P = .027). The largest improvement was found among the uninsured population (hazard DID: -0.0038, 95% CI = -0.0076 to -0.0011, P = .013). In sensitivity analyses with abbreviated data through 2019, results were similar (DID for 1-year OS: 1.3%; hazard DID: -0.0010, 95% CI = -0.0025, 0.0001, P = .070). Conclusions: State mandatory paid medical leave was associated with improved survival for working-age adults with newly diagnosed cancer, particularly for those who are uninsured. Policy changes that better support patients through cancer treatment may pay off with improved cancer outcomes.

Case Ascertainment of Sickle Cell Disease Using Surveillance or Single Administrative Database Case Definitions.

In the absence of access to surveillance system data, single-source administrative databases are often used to study health care utilization and health outcomes among people with sickle cell disease (SCD). We compared the case definitions from single-source administrative databases with a surveillance case definition to identify people with SCD. We used data from Sickle Cell Data Collection programs in California and Georgia (2016-2018). The surveillance case definition for SCD developed for the Sickle Cell Data Collection programs uses multiple databases, including newborn screening, discharge databases, state Medicaid programs, vital records, and clinic data. Case definitions for SCD in single-source administrative databases varied by database (Medicaid and discharge) and years of data (1, 2, and 3 years). We calculated the proportion of people meeting the surveillance case definition for SCD that was captured by each single administrative database case definition for SCD, by birth cohort, sex, and Medicaid enrollment. In California, 7117 people met the surveillance case definition of SCD from 2016 through 2018; 48% of this group was captured by the Medicaid case definition and 41% by the discharge case definition. In Georgia, 10 448 people met the surveillance case definition of SCD from 2016 through 2018; 45% of this group was captured by the Medicaid case definition and 51% by the discharge case definition. These proportions differed by years of data, birth cohort, and length of Medicaid enrollment. The surveillance case definition identified twice as many people with SCD as the single-source administrative database definitions during the same period, but trade-offs exist in using single administrative databases for decisions on policy and program expansion for SCD.

State Medicaid and private telemedicine coverage requirements and telemedicine use, 2013-2019.

To examine the association between state Medicaid and private telemedicine coverage requirements and telemedicine use. A secondary objective was to examine whether these policies were associated with health care access. We used nationally representative survey data from the 2013-2019 Association of American Medical Colleges Consumer Survey of Health Care Access. The sample included Medicaid-enrolled (4492) and privately insured (15,581) adults under age 65. The study design was a quasi-experimental two-way-fixed-effects difference-in-differences analysis that took advantage of state-level changes in telemedicine coverage requirements during the study period. Separate analyses were conducted for the Medicaid and private requirements. The primary outcome was the past-year use of live video communication. Secondary outcomes included same-day appointment, always able to get needed care, and having enough options for where to go to receive care. N/A. Medicaid telemedicine coverage requirements were associated with a 6.01 percentage-point increase in the use of live video communication (95% CI, 1.62 to 10.41) and an 11.12 percentage-point increase in always being able to access needed care (95% CI, 3.34 to 18.90). While generally robust to various sensitivity analyses, these findings were somewhat sensitive to included study years. Private coverage requirements were not significantly associated with any of the outcomes considered. Medicaid telemedicine coverage during 2013-2019 was associated with significant and meaningful increases in telemedicine use and health care access. We did not detect any significant associations for private telemedicine coverage policies. Many states added or expanded telemedicine coverage policies during the COVID-19 pandemic, but states will face decisions about whether to maintain these enhanced policies now that the public health emergency is ending. Understanding the role of state policies in promoting telemedicine use may help inform policymaking efforts going forward.

Impact of Medicaid expansion on inclusion of medications for opioid use disorder in homeless adults' treatment plans

IntroductionPeople experiencing homelessness (PEH) bear disproportionate opioid mortality. This article aims to determine how state Medicaid expansion under the Affordable Care Act impacted the inclusion of medications for opioid use disorder (MOUD) in treatment plans for housed versus homeless individuals. MethodsThe Treatment Episodes Data Set (TEDS) provided data on 6,878,044 U.S. treatment admissions between 2006 and 2019. Difference-in-differences analysis compared MOUD treatment plans and Medicaid enrollment for housed versus homeless clients in states that did and did not expand Medicaid. ResultsMedicaid expansion was associated with a 35.2 (95 % CI, 11.9 to 58.4) percentage point increase in Medicaid enrollment and an 8.51 (95 % CI, 1.13 to 15.9) percentage point increase in MOUD-inclusive treatment plans for housed and homeless clients alike. Yet the pre-existing MOUD disparity persisted, with PEH being 11.8 (95 % CI, −18.6 to −5.07) percentage points less likely to have MOUD-inclusive treatment plans. ConclusionsMedicaid expansion may be an effective tool for increasing MOUD treatment plans for PEH in the 11 states that have not yet implemented the policy, but additional efforts to increase MOUD initiation for PEH will be necessary for closing their treatment gap.

Burden of Crohn’s Disease in the United States Medicaid Population, 2010–2019

Twenty-five percent of the United States population is enrolled in Medicaid. Rates of Crohn's disease (CD) have not been estimated in the Medicaid population since the Affordable Care Act expansion in 2014. We aimed to estimate the incidence and prevalence of CD by age, sex, and race. We identified all 2010-2019 Medicaid CD encounters using codes from the International Classification of Diseases, Clinical Modification versions 9 and 10. Individuals with ≥2 CD encounters were included. Sensitivity analyses were performed on other definitions (eg, ≥1 CD encounter). Incidence required ≥1 year of Medicaid eligibility prior to first CD encounter date (2013-2019). We calculated CD prevalence and incidence using the entire Medicaid population as the denominator. Rates were stratified by calendar year, age, sex, and race. Poisson regression models examined CD-associated demographic characteristics. We compared demographics and treatments of the entire Medicaid population with the multiple CD case definitions using percent and median. A total of 197,553 beneficiaries had ≥2 CD encounters. The CD point prevalence per 100,000 persons rose from 56 (2010) to 88 (2011) to 165 (2019). CD incidence per 100,000 person-years was 18 (2013) and 13 (2019). Higher incidence and prevalence rates correlated with female, white, or multiracial beneficiaries. Prevalence rates rose in later years. Incidence decreased over time. From 2010 to 2019, Medicaid population CD prevalence increased while incidence decreased from 2013 to 2019. Overall Medicaid CD incidence and prevalence ranges align with prior large administrative database studies.

Analytic Framework to Improve Access for a State Medicaid Agency

Analytics can help identify strategies to improve the equity and capacity of health services for populations. However, many government agencies experience challenges with heavy workloads, limited time for continued analytic education, and employee turnover among contracted staff. Therefore, streamlining analytical workflows has the potential to (1) improve labor cost-efficiencies and (2) identify strategies to improve health among enrollees. We describe an analytic framework design that automates several empirical methods and provides recommendations for increasing healthcare access for Alabama Medicaid Agency (AMA) enrollees. The described framework, which includes descriptive and prescriptive elements, has been successfully used to inform various day-to-day analyses conducted by AMA’s Analytics Department and comprehensively analyze AMA-enrolled youths’ accessibility to licensed dentists. Specifically, in the dental context, the framework assisted in identifying (1) dental procedures that were ideal candidates for increased reimbursement payments and (2) geographical locations that AMA should target for interventions to improve physical access to care for AMA’s youth enrollees. The insights offered by the framework for dental care impact more than 0.5 million underserved youth and roughly $90 million of annual revenue for licensed dentists through reimbursements. History: This paper was refereed. Funding: D. Lewis, J. Parton, M. Hudnall, R. Tramp, X. T. Yang, and S. Samsel received salary support from the Alabama Medicaid Agency during the execution of this study. B. Cambron, T. Tyner, N. Biligowda, and D. Rush were employed at the Alabama Medicaid Agency during the execution of this study. The other authors do not declare the receipt of funding associated with entities affiliated with this study.

CMS Finalizes New Medicare Advantage Prior Authorization Rule

CMS Finalizes New Medicare Advantage Prior Authorization Rule

Hospital concentration and low-income populations: Evidence from New York State Medicaid

While a large body of evidence has examined hospital concentration, its effects on health care for low-income populations are less explored. We use comprehensive discharge data from New York State to measure the effects of changes in market concentration on hospital-level inpatient Medicaid volumes. Holding fixed hospital factors constant, a one percent increase in HHI leads to a 0.6% (s.e. = 0.28%) decrease in the number of Medicaid admissions for the average hospital. The strongest effects are on admissions for birth (-1.3%, s.e. = 0.58%). These average hospital-level decreases largely reflect redistribution of Medicaid patients across hospitals, rather than overall reductions in hospitalizations for Medicaid patients. In particular, hospital concentration leads to a redistribution of admissions from non-profit hospitals to public hospitals. We find evidence that for births, physicians serving high shares of Medicaid beneficiaries in particular experience reduced admissions as concentration increased. These reductions may reflect preferences among these physicians or reduced admitting privileges by hospitals as a means to screen out Medicaid patients.

Testing dental quality measures: Emergency department visits for nontraumatic dental conditions and subsequent follow-up dental visits

BackgroundThe goal of this study was to test the feasibility, reliability, and validity of the Dental Quality Alliance’s adult dental quality measures for system-level implementation for ambulatory care sensitive (ACS) emergency department (ED) visits for nontraumatic dental conditions (NTDCs) in adults and follow-up after ED visits for NTDCs in adults. MethodsMedicaid enrollment and claims data from Oregon and Iowa were used for measure testing. Testing included validation of diagnosis codes in claims data through patient record reviews of ED visits and calculations of κ statistic, sensitivity, and specificity. ResultsAdult Medicaid enrollees’ ACS NTDC ED visits ranged from 209 through 310 per 100,000 member-months. In both states, patients in the age category 25 through 34 years and non-Hispanic Black patients had the highest rates of ACS ED visits for NTDCs. Only one-third of all ED visits were associated with a follow-up dental visit within 30 days, decreasing to approximately one-fifth with a 7-day follow-up. The agreement between the claims data and patient records for identification of ACS ED visits for NTDCs was 93%, κ statistic was 0.85, sensitivity was 92%, and specificity was 94%. ConclusionsTesting revealed the feasibility, reliability, and validity of 2 DQA quality measures. Most beneficiaries did not have a follow-up with a dentist within 30 days of an ED visit. Practical ImplicationsAdoption of quality measures by state Medicaid programs and other integrated care systems will enable active tracking of beneficiaries with ED visits for NTDCs and develop strategies to connect them to dental homes.

Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter?

To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies. Retrospective cross-sectional study. The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31,2017. 2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies. Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR= 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR= 1.16, P < .01). Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.

APA’s Government, Policy, and Advocacy Update (May 2023)

Back to table of contents Previous article Next article Government & LegalFull AccessAPA’s Government, Policy, and Advocacy Update (May 2023)Search for more papers by this authorPublished Online:25 Apr 2023https://doi.org/10.1176/appi.pn.2023.05.5.19APA, AACAP Ask DEA About Plans To Address Stimulant ShortageIn a letter to Drug Enforcement Administration (DEA) Administrator Anne Milgram, J.D., APA and the American Academy of Child and Adolescent Psychiatry (AACAP) asked what actions are being taken by the DEA to improve the nation’s supply of stimulant medications and requested a time to meet with DEA staff to address the situation.“The nation has grappled with a stimulant medication shortage since October of last year, starting with the Adderall shortage, linked to Teva manufacturing delays,” the organizations wrote. “Many child and adolescent psychiatrists, general psychiatrists, and other physicians have been forced to switch their patients’ medications, transitioning them to non-Adderall stimulant alternatives, which has its own set of potential pitfalls, including not working as well to curb symptoms of ADHD and commonly occurring comorbid mental disorders.”The increased demand for stimulant medications other than Adderall has resulted in further shortage of Ritalin and Concerta, the organizations noted. The letter included several firsthand accounts from clinicians who shared the stress and anxiety the situation has caused, as well as the huge amount of time it has taken to help patients and families find medications. The clinicians detailed the onerous process of calling different pharmacies, dealing with prior authorization requests, and working with parents and schools to create emergency plans for children who must go days without their medications due to the shortages.APA and AACAP’s Letter to the DEA on the Stimulant Shortage APA Responds to CMS’s Proposed Interoperability, Prior Authorization RuleIn December, the Centers for Medicare and Medicaid Services (CMS) proposed a rule to advance the agency’s interoperability goals and address some challenges related to prior authorization “to increase efficiencies in health care,” according to a CMS fact sheet. The rule would place new requirements on Medicare Advantage organizations, state Medicaid programs, and insurers that offer plans on the federal marketplace to improve the electronic exchange of health care data and streamline their prior authorization processes.In a letter to CMS Administrator Chiquita Brooks-LaSure, M.P.P., APA commented on numerous aspects of the proposed rule and recommended some revisions focused on equity and effectiveness. “To effectively focus efforts on standardization and interoperability, the root causes of technological inequity in clinical mental health settings need to be addressed through financial incentives, technical assistance, and learning networks,” APA’s letter, signed by APA CEO and Medical Director Saul Levin, M.D., M.P.A., stated.Some of APA’s recommendations include incorporating patient protections related to using apps and increasing funding for research related to standardizing and validating the tools and processes used to collect information.APA’s Letter on Interoperability and Prior Authorization APA Provides Workforce Recommendations To Senate HELP CommitteeThe Senate Health, Education, Labor, and Pensions (HELP) Committee requested information in February on the drivers behind the health care workforce shortage and potential solutions. APA submitted its response in a letter signed by Levin, highlighting various programs, many of which are under the Health Resources and Services Administration (HRSA), that should receive continued or increased funding to address the workforce shortages worsened by the COVID-19 pandemic.The letter highlighted the importance of several HRSA programs, including the Substance Use Disorder Treatment and Recovery Loan Repayment Program, the Pediatric Subspecialty Loan Repayment Program, and the Children’s Hospitals Graduate Medical Education Program.Further, the letter emphasized the effectiveness of the Collaborative Care Model in expanding the footprint of the existing behavioral health workforce, the importance of expanded access to telepsychiatry, and the need to invest in programs that improve workforce diversity.APA’s Letter to the HELP Committee APA Thanks Senators for Reintroducing Bill to Benefit TraineesAlong with dozens of medical organizations, APA sent a letter to Sens. Jacky Rosen (D-Nev.) and John Boozman (R-Ark.), thanking them for the reintroduction of the Resident Education Deferred Interest (REDI) Act. The legislation would allow borrowers to qualify for interest-free deferment on their student loans while serving in a medical or dental internship or residency program.“Passage of the REDI Act is an important part of student loan repayment reform,” the organizations wrote. ■The Letter in Support of the REDI Act ISSUES NewArchived

Medicaid Coverage for Routine Foot Care.

Despite national and international guidelines supporting podiatric services as a means of prevention for lower-extremity complications, especially in at-risk individuals, current coverage for these services under the US Medicaid program is not universal. The vast differences between state Medicaid programs regarding reimbursable foot care services is confusing and potentially serves as a barrier for the most vulnerable populations to receive preventative services. This article provides a brief discussion of "routine" podiatric services from a clinical perspective and provides a review of state Medicaid programs including optional services (eg, podiatric coverage). Using data from a national survey of state Medicaid programs, we present and discuss common Medicaid coverage schemes for routine foot care provided by podiatric physicians. Analysis demonstrated that states vary dramatically in basic descriptions of preventive foot care, levels of coverage, eligibility, and methods of documenting coverage details. The authors recommend bringing Medicaid in line with other federal health programs and including podiatric physicians in the definition of "physician" for coverage purposes. States should move away from describing preventative services as "routine" and choose language that more accurately reflects the true nature and purpose of the care.

Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use.

To increase access to highly effective contraception and improve reproductive autonomy, a growing number of state Medicaid programs pay for the provision of immediate postpartum long-acting reversible contraception (LARC) in addition to providing a global payment for maternity care. Using Pregnancy Risk Assessment Monitoring System data, we examined postpartum LARC use both overall and by race and ethnicity among respondents with Medicaid-paid births during the period 2012-18 in eight states that implemented immediate postpartum LARC payment and eight states without it. Using a quasi-experimental difference-in-differences design, we found that the policy resulted in an overall 2.1-percentage-point increase in postpartum LARC use. Our triple-differences analysis found no significant change among White mothers and a 3.7-percentage-point increase in use among Black mothers compared with White mothers. Additional research is needed to determine whether this increase was aligned with patients' preferences and whether hospitals' immediate postpartum LARC policies and practices take a patient-centered approach that supports reproductive autonomy and equity.

Insurance Trends in Patients Diagnosed with Melanoma Before and After the Affordable Care Act: A National Database Study

Background: The Affordable Care Act (ACA) was intended, in part, to reduce the uninsured population. It underwent full implementation in 2014 with optional state Medicaid expansion and health insurance marketplaces. Prior to the ACA, studies show that insurance status affects cancer care, including prevention, diagnosis, stage at diagnosis, and management. ACA impact on malignant melanoma is unknown. In this study, the primary objective is to examine the impact of the ACA on insurance rates among patients diagnosed with malignant melanoma. Survival by insurance type was also assessed. Methods: A retrospective analysis of the Surveillance, Epidemiology and End Results (SEER) cancer registry was performed for malignant melanoma between 2007 (first year of insurance da-ta in SEER) and 2015. Standardized mean differences were used for 2007-2013 and 2014-2015 (after full ACA implementation) for the primary objective. Sub-analysis was performed for Med-icaid expansion and non-expansion states. The impact of insurance type (uninsured, Medicaid, non-Medicaid) on all-cause and cause-specific mortality was assessed via adjusted cox regression models. Results: Nationally, the ACA decreased percentage of uninsured patients (-1.12% to -2.26%, P&lt;0.05) and increased percentage of Medicaid enrollees (+1.53% to +4.02%, P&lt;.005) diagnosed with malignant melanoma. Expansion states showed decreased percentage of uninsured patients (-1.43% to -2.24%, P&lt;0.05) and increased percentage of Medicaid enrollees (+1.66% to +4.84%, P&lt;0.05). Non-expansion states showed no change in percentages of uninsured patients and Medicaid enrollees. All-cause and cause-specific mortality were decreased in uninsured and Medicaid patients diagnosed with malignant melanoma compared to non-Medicaid insured patients (reference group). Discussion: The ACA decreased the rate of patients diagnosed with malignant melanoma with uninsured status, but this was only significant in Medicaid expansion states. Although diagnosis of melanoma is associated with High Socioeconomic Status (SES), Medicaid expansion seems to have increased access to dermatologic care. Increasing the number of states expanding Medicaid may be beneficial. However, Medicaid patient have worse all-cause and cause-specific mortality compared to non-Medicaid insured patients. Addressing these disparities through policy is important to ensure insurance coverage translates to better outcomes.